More and more Americans with mental health concerns are becoming incarcerated. This population of has reached “crisis proportions,” according to the National Alliance on Mental Health (NAMI).

Evidence shows incarceration is likely to worsen mental health symptoms. Most institutions do not have the resources to treat such a great number of people. Reduced mental health can lead to recidivism, meaning a recurrence of criminal behavior. When more people are rearrested, the population of imprisoned people stays high.

However, there are ways to reduce recidivism in these populations. People who receive mental health treatment during and after their sentences are less likely to reoffend. Alternatives to imprisonment can also reduce recidivism.

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Mental Health in the Criminal Justice System

In the United States, around 2 million people go to jail or prison each year. In general, jails are run by local forces. They hold inmates for terms of one year or less. Prisons are run by state or federal forces. They typically house prisoners for longer periods.

Many people in prisons and jails have a mental health diagnosis.

• A 2005 Department of Justice study found 64% of inmates in local jails have a mental health concern. The rates were 56% for state prisoners and 45% for federal prisoners.
• Around 50% of incarcerated people have a dual diagnosis. A dual diagnosis occurs when someone has both a mental health concern and substance addiction.
• According to NAMI, 20% of incarcerated individuals been diagnosed with “serious mental illness.” Someone with a “serious” condition may require daily assistance. This category includes conditions such as schizophrenia, major depression, and bipolar.

Estimates on recidivism rates vary. Most studies show offenders with diagnoses have higher recidivism rates than those without.

• The 2005 study above found 75% of incarcerated individuals with a diagnosis had been arrested before.
• A 2017 study showed offenders with diagnoses have a 9% greater chance of rearrest one year after release. Five years after release, the difference increases to 15%.
• The same 2017 study found people with severe diagnoses are 4% more likely to be rearrested than those with milder conditions.

How Jails and Prisons Became Mental Health Facilities

The criminal justice system has not favored people with mental health concerns in the past. From straitjackets to lobotomies, history is full of inhumane attempts to manage mental health. Pervasive stigma impacted nearly every step of incarceration and treatment.

In the 1950s and 1960s, the government closed many mental institutions and psychiatric hospitals. The intent was to serve people through community resources instead. Yet a lack of funding and commitment left many states with few treatment options.

In a Stanford Law Report, Senator Darrell Steinberg and Professor David Mills write, “Although deinstitutionalization was originally understood as a humane way to offer more suitable services … in community-based settings, some politicians seized upon it as a way to save money by shutting down institutions without providing any meaningful treatment alternatives.”

Many prisons and jails are ill-equipped to provide adequate mental health care. But for some people, these facilities are where they first encounter treatment. In the 1980s, the “war on drugs” complicated matters. The government began assigning mandatory sentences for drug-related offenses. More people with substance addiction were put behind bars. Many of these people had co-occurring mental health concerns. In the last 40 years, the rate of incarceration has increased five-fold in the U.S.

People with mental health issues are more likely to be the victim of a crime than commit one. Yet research shows living with untreated conditions can be extremely damaging to individuals. An untreated condition may affect a person’s judgment and lead to criminal behavior. This likelihood increases if other large-scale stressors (poverty, abuse, etc.) are present.

Many prisons and jails are ill-equipped to provide adequate mental health care. But for some people, these facilities are where they first encounter treatment. A person may not get a diagnosis until they are already behind bars.

The Incarceration Cycle for People with Mental Health Concerns

Today’s criminal justice system treats individuals more humanely than in the past. Yet offenders with mental health concerns still face discrimination. Someone with a diagnosis is likely to get a longer, harsher sentence than a neurotypical peer convicted of the same crime. They are also less likely to be granted release.

Incarceration itself can worsen mental health. Offenders often experience a drastic drop in agency. Strict rules and isolation can exacerbate stress. An individual may develop additional mental health concerns as they adjust to the transition.

Incarceration itself can worsen mental health.The Bureau of Justice Statistics held a survey asking offenders about their mental health in the prior 30 days. Fourteen percent of state or federal prisoners reported having severe psychological distress. The rate was almost double (26%) for jail inmates.

Compromised mental health and relative isolation can promote substance abuse. Andrew Archer, LCSW explains, “American incarceration operates as a perfect recipe to perpetuate habitual patterns for individuals. Extreme isolation and societal alienation demoralize the person to the extent that often times substances are the only form of self-regulation.”

In this way, alcohol and drug addiction can spread through populations of offenders. The sale, trade, and consumption of drugs can broaden one’s criminal network. Being insulated with other offenders can also reinforce attitudes that encourage further crime.

After years of incarceration, prisoners tend to struggle once they are released. Trey Cole, PsyD, says, “Relationally speaking, incarcerated individuals often become accustomed to the externally controlled environment (i.e. when to eat, sleep, etc.). When released, then, usually with few resources, becoming accountable to oneself and internally motivated become more difficult.”

Released offenders may find themselves without any resources or support. They may struggle to find housing or employment due to stigma. Reduced mental health can also impact one’s ability to make a living.

In other words, the factors which led a person to crime may be even stronger after release. Their ability to survive within the law may have been reduced. In this context, a person can easily be drawn into recidivism.

Compassionate Solutions for Lowering Recidivism Rates

A report by the Council of State Governments (CSG) Justice Center calls for an overhaul of the way U.S. criminal justice systems address people with mental health issues. Special attention was called to the way such people are released from jail and prison.

According to the CSG, a successful system of reentry into society would:

• Combine a range of services and professional efforts.
• Coordinate treatment for substance abuse and other mental health issues.
• Integrate both mental health care and primary healthcare.
• Provide housing for individuals with mental health issues.
• Draw upon family connections and community resources for treatment.
• Ensure people can access the full range of government entitlements for which they are eligible, such as Social Security Disability Insurance.

Some states have already begun to implement these measures. Colorado, Texas, and North Carolina have used grant money to expand mental health care and substance abuse treatment for offenders. These states also saw large drops in recidivism.

• North Carolina had a 42% reduction in people sent back to prison after probation violations between 2006 and 2015.
• Texas had a 25% reduction in the 3-year reincarceration rate between 2004 and 2013.
• Colorado saw probation revocations and the 3-year reincarnation rate reduced by at least 23% in around the same time frame.

How Diversion can Reduce Recidivism

Diversion has also been shown to reduce recidivism rates in people with mental illness. Diversion is a practice of placing offenders in mental health treatment instead of prison or jail. It often takes one of two forms.

The first form is forensic hospitalization. Offenders who have been found not guilty by reason of insanity are typically sent to forensic hospitals. These facilities do confine people like prisons and jails do. Yet their aim is typically rehabilitation rather than punishment. Less than 1% of people in the criminal justice system qualify for the insanity defense.

A 2005 study found offenders released from forensic hospitals had very low recidivism rates. They were less likely to reoffend than released inmates with mental health concerns. They were also less likely to offend than inmates without a diagnosis.

It is often cheaper to send nonviolent offenders to mental health treatment than jail. The other path of diversion involves mental health courts. These courts are for offenders who have mental health concerns but don’t qualify for the insanity defense. Judges may offer defendants reduced sentences in exchange for getting treatment. In many cases, a defendant may not go to jail or prison at all.

A 2007 study found participation in mental health courts cut the risk of violent offense in half. People who had gone through mental health courts also went longer without reoffending than those who went through traditional courts.

NAMI strongly supports diversion as a more humane and cost-effective approach to incarceration. According to NAMI, the cost of jailing adults with mental health concerns is two to three times the cost of keeping other inmates. It is often cheaper to send nonviolent offenders to mental health treatment than jail.

Just as psychotherapists who practice good therapy see people as whole beings independent of any mental health issues they may have, NAMI’s compassionate justice system would see all individuals as worthy of treatment and change. This system would classify mental health concerns not as moral defects, but as results of adversity or strain. Prioritizing treatment over punishment could have lasting benefits for the criminal justice system.

References:

1. Agnew, R. (2001). Building on the foundation of general strain theory: Specifying the types of strain most likely to lead to crime and delinquency. Journal of Research in Crime and Delinquency, 38(4), 319-361. Retrieved from http://journals.sagepub.com/doi/abs/10.1177/0022427801038004001
2. Bales, W.D., Nadel, M., Reed, C. & Blomberg, T. G. (2017). Recidivism and inmate mental illness. International Journal of Criminology and Sociology, 6(1) 40-51.
3. Bloom, J. D., & Novosad, D. (2017). The Forensic Mental Health Services Census of forensic populations in state facilities. The Journal of the American Academy of Psychiatry and the Law, 45(4), 447-451. Retrieved from http://jaapl.org/content/45/4/447
4. Bronson, J. & Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011-12. Bureau of Justice Statistics. Retrieved from https://www.bjs.gov/content/pub/pdf/imhprpji1112.pdf
5. Criminals need mental health care. (2014, March 1). Scientific American. Retrieved from https://www.scientificamerican.com/article/criminals-need-mental-health-care
6. What is the difference between jails and prisons? (n.d.). Bureau of Justice Statistics. Retrieved from https://www.bjs.gov/index.cfm?ty=qa&iid=322
7. Lerman, A. E. (2013). The modern prison paradox: Politics, punishment, and social community. Cambridge University Press. Retrieved from https://gspp.berkeley.edu/research/selected-publications/the-modern-prison-paradox-politics-punishment-and-social-community
8. NAMI warns senate about criminalization of mental illness; Supports Cornyn bill. (2016, February 10). NAMI. Retrieved from https://www.nami.org/Press-Media/Press-Releases/2016/NAMI-Warns-Senate-about-Criminalization-of-Mental
9. The new asylums: Some frequently asked questions. (2005, May 10). PBS. Retrieved from https://www.pbs.org/wgbh/pages/frontline/shows/asylums/etc/faqs.html
10. Reducing recidivism: States deliver results. (2017). The Council of State Governments Justice Center. Retrieved from https://csgjusticecenter.org/wp-content/uploads/2018/03/Reducing-Recidivism_State-Deliver-Results_2017.pdf
11. Steinberg, D. & Mills, D. (n.d.) When did prisons become acceptable mental health care facilities? Stanford Law School: Three Strikes Project. Retrieved from http://law.stanford.edu/wp-content/uploads/sites/default/files/child-page/632655/doc/slspublic/Report_v12.pdf

Many people curb their nervousness with a nice glass of wine or other alcohol beverage. Whether you’re gathering the courage to socialize with people you barely know, fly on an airplane, or even if you’re just feeling worried about the future, alcohol can help loosen inhibitions and dampen self doubt and fears.  While you may feel more relaxed temporarily, using alcohol to tame your anxiety can backfire in the long run.

Immediate Effects

Even though you may be feeling calmer after the first one or two drinks, your body is processing the alcohol and the physiological effects can actually trigger feelings of anxiety. Alcohol can negatively impact blood sugar levels each time that it is consumed. Research has shown that the body responds to alcohol by increasing insulin secretion, causing low blood sugar and also impairs the body’s hormonal response that would normally be able to normalize blood sugar levels. Drinking as little as two ounces of alcohol on an empty stomach can lead to very low blood sugar levels. Low blood sugar levels can cause dizziness, confusion, weakness, nervousness, shaking and numbness, all of which can mimic the symptoms of anxiety, or even trigger an episode of anxiety.

Alcohol consumption can also cause dehydration. Alcohol is a fairly strong diuretic, meaning that the body loses water by producing an increased amount of urine. Symptoms of dehydration include dizziness, muscle weakness, lightheadedness and nausea, again, all of which can mimic symptoms of anxiety, or induce anxious reactions related to the fear of being ill.

Alcohol consumption has a sedative effect on the body. It is a drug that depresses the central nervous system. Immediate effects are a sense of euphoria, decreased inhibitions, and lessened anxiety. However, over time the chronic use of alcohol could result in tolerance, dependency, and damage to many organs of the body including the brain, liver, and heart.

Longer Term Effects

People with anxiety are up to three times more likely to have an alcohol problem or other substance abuse than those without anxiety. It takes increasingly larger amounts of alcohol to achieve the same effects, leading to alcohol dependence. Long-term alcohol use can have multiple negative effects on the body and aggravate existing anxiety.

Recent studies have shown that heavy drinking or long term drinking stresses the body and causes it to have higher levels of the stress hormone, cortisol. Cortisol is necessary in short term stress situations because it helps focus alertness and attention, but cortisol also suppresses bodily functions such as wound repair, bone growth, digestion, and reproduction. Chronically high cortisol levels therefore interfere with these important processes in the body. Alcohol use also depletes the body of vitamin B6 and folic acid, which the body needs to help cope with stress. Long-term exposure to alcohol reduces the levels of the GABA-benzodiazepine receptor in the central nervous system and reduces the brain’s ability to calm the mind and the body and cope with anxiety in the long run.

Serotonin is a chemical in the body which is needed for memory, learning, and especially for feelings of ‘wellbeing”. Drinking alcohol can temporarily boost serotonin levels, therefore making you feel happier, but in the long term, excess alcohol can actually lower serotonin levels, and therefore either causing or exacerbating depression.

In another recent study, researchers found that high anxiety levels in humans are related to a deficiency in an important protein called CREB, which is needed by the amygdala, the area of the brain where emotions are processed. The amygdala is important in calming anxious thoughts. The study results showed that drinking alcohol boosts the CREB levels in the brain and therefore lessens anxiety, which helps to explain why so many anxious people us alcohol to self-medicate. The good news is that there are other, healthier ways to naturally raise CREB levels, such as getting regular exercise and listening to music. Some antidepressants can also help raise CREB levels also.

So, even though using alcohol is an easy, short term fix for anxious feelings, you’re not doing your body or your mind any favors by self-medicating with alcohol. Learning to manage anxiety (and naturally boost your CREB levels) in healthy ways such as through exercise, music, and expressing creativity is possible.  Psychotherapy can also be very helpful. In fact, research shows that psychotherapy is usually the most effective long-term treatment for anxiety disorders. Therapy treats more than just the symptoms of anxiety. It helps you discover the underlying causes of your worries and fears.  In therapy, you’ll learn to relax, perceive and interpret situations in new, less frightening ways, and learn better coping and problem-solving skills. Through therapy, you learn the tools to overcome anxiety and how to use them effectively.